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Health Care Reform: FAQ on Various Affordable Care Act Issues


February 2013

A new FAQ was issued by the DOL, HHS, and IRS providing further guidance under the Affordable Care Act concerning limitations on cost-sharing, and expansive guidance concerning coverage of preventive services. The FAQ further expands on the topic discussed in the HHS final regulations noted above. In particular, the FAQ states that while all non-grandfathered group health plans must comply with the annual limitation on out-of-pocket maximums, some transitional relief applies in 2014. Only for the first plan year beginning on or after January 1, 2014, where a group health plan utilizes more than one service provider to administer benefits, the agencies will consider the annual limitation on out-of-pocket maximums to be satisfied if both of the following conditions are satisfied: (a) the plan complies with these requirements with respect to its major medical coverage (excluding, for example, prescription drug coverage and pediatric dental coverage); and (b) to the extent the plan or any health insurance coverage includes an out-of-pocket maximum on coverage that does not consist solely of major medical coverage (for example, if a separate out-of-pocket maximum applies with respect to prescription drug coverage), such out-of-pocket maximum does not exceed dollar amounts noted above (currently $6,250 for self-only coverage, and $12,500 for non-self only coverage in 2013).

The new FAQ also provides substantial guidance on coverage of preventive services. In particular, the FAQ confirmed the common understanding that group health plans cannot limit coverage of contraceptives to oral contraceptives. The applicable guidelines ensure women’s access to the full range of FDA-approved contraceptive methods including, but not limited to, barrier methods, hormonal methods, and implanted devices, as well as patient education and counseling, as prescribed by a health care provider. Nevertheless, plans may use reasonable medical management techniques to control costs and promote efficient delivery of care – for example, by covering a generic drug without cost-sharing and imposing a co-pay or other cost-sharing for equivalent brand drugs.

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